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Putting Malaria on the Defensive

WASHINGTON, D.C.--A combination of subsidies and more aggressive drug cocktails is the most effective way to fight malaria, according to panelists at a global health policy meeting here yesterday sponsored by the journal Health Affairs.

Malaria has managed to elude several major attempts to bring it under control. First, the mosquito that hosts the parasite showed resistance to DDT. Then the parasite itself defied drugs such as chloroquine. And now researchers are worried that another drug called artemisinin--widely viewed as the last line of defense against the disease--may soon fail as well (Science, 3 February 2006).

To tackle the resistance problem, the panel urges the expanded use of a cocktail therapy strategy, similar to that used against HIV. Such cocktails combine artemisinin with other drugs such as amodiaquine or lumefantrine, which fight the disease in different ways. While artemisinin combination therapy (ACT) is not new, panelist and epidemiologist Ramanan Laxminarayan of the Washington D.C.-based think tank Resources for the Future, says an updated strategy would encourage the use of at least two types of ACT at the same time in a given area. Such an approach, he says, would greatly reduce the chances of the malaria parasite developing resistance to the cocktails.

It's a costly proposition. Multiple ACT cocktails would run about $1.30 per treatment course--a large sum for poorer countries. To soften the blow, Laxminarayan recommends a global subsidy of $150 million per year to be funded by an international community of donor governments. Using a bioeconomic model, Laxminarayan found than even a partial subsidy of ACT combinations now "could save up to 25,000 lives every month." Not providing any support, even for a few years, could result in the parasite becoming resistant to all known treatments, he says. Laxminarayan and colleagues will present their findings in the March/April issue of Health Affairs.

Economist Ken Arrow of Stanford University in California believes a subsidy is feasible. "There is now a subsidy for tuberculosis and one for retroviral drugs," he says, "so it's a possibility." However, he cautions that drugs are only one element in the fight against malaria. "We need to supplement them with environmental controls" that target mosquitoes such as "bed nets or drainage of breeding areas," he says.